postoperatively, the patient’s uncor- revealed a serous retinal detach-

Figure 3. Corneal topography of the left eye after
laser-assisted in situ keratomileusis and prior to
enhancement.
postoperatively, the patient’s uncorrected vision was 20/50 OS. The left
eye was correctable to 20/20 with
+1.50−1.75⫻60.
The patient was followed up every 2 weeks for 5 months until his vision and refraction stabilized in the
left eye (without correction, visual
acuity was 20/200 and with correction, −1.75−2.50⫻45, visual acuity
was 20/20). Keratometry in the left
eye at this time was 41.25 D at 136
degrees, 38.75 D at 46 degrees, and
pachymetry in the left eye was 572
µm. Thetopography of the left eye just
prior to the enhancement is shown
(Figure 3). The left eye was retreated
on January 15, 2003, for −1.8 − 2.50
⫻45. The flap was not recut but lifted
up with some difficulty, as it had
adhered very strongly to the corneal
bed. At 1 day postoperatively, the uncorrected vision was 20/20 OS.
The final uncorrected distance vision, 3 months after retreatment, was
20/20−1 OS. Uncorrected near vision was Jaeger measure 2 OS. The
patient was very happy with his final visual outcome.
This is the first known case of
LASIK for myopia being performed after epikeratophakia. This
report shows that LASIK following
epikeratophakia can be performed
successfully.
Eileen Conti, MD
Correspondence: Dr Conti, 121 Rte
31, Suite 200, Flemington, NJ 08822
(contieyecare@aol.com).
Macular Schisis Detachment
Associated With
Angle-closure Glaucoma
Optic disc pits represent congenital anomalies in the optic nerve head
commonly associated with retinoschisis and serous retinal detachments.1 In contrast, acquired glaucomatous damage to the optic nerve,
both localized acquired pits and diffuse Schnabel optic atrophy, has not
been linked to retinal detachment.
A recent report by Spaide et al2 demonstrated schisis and outer layer detachment, the characteristic features of optic pit maculopathy, in the
absence of an optic pit. We describe a patient who developed
macular schisis and underlying serous detachment in an eye with a
large optic cup following repeated attacks of angle-closure glaucoma.
Report of a Case. A 54-year-old man
was seen by an ophthalmologist and
complained of 4 weeks of intermittent pain and blurring of vision in
his right eye. A right afferent pupillary defect was present, and the visual acuity was 20/200 OD and 20/25
OS. At examination, the intraocular pressure in his right eye was 52
mm Hg. Gonioscopy revealed angle
closure in his right eye and narrow
angles in his left eye. The patient was
treated with bilateral peripheral iridotomies and topical glaucoma
medications. Fundus examination
(REPRINTED) ARCH OPHTHALMOL / VOL 123, FEB 2005
270
revealed a serous retinal detachment in the right eye.
During the next 3 months, the patient noted enlargement of a central scotoma in his right eye, and he
was referred to the retina service at
the University of California, San
Francisco. The visual acuity in his
left eye had remained stable, yet that
in the right eye had dropped to 20/
800 OD. Significant asymmetry of
the optic nerves was observed, with
cup-disc ratios of 0.9 OD and 0.2 OS
(Figure 1). The fundus of the left
eye was unremarkable, but the right
eye had a serous retinal detachment with fluid extending from the
disc margin through the macula
(Figure 2A), as well as a posterior
vitreous detachment. Contact lens
examination revealed a small area of
dehiscence in the internal limiting
membrane just temporal to the right
optic disc.
An area of hyperfluorescence
deep in the central and inferotemporal margin of the right optic cup
without leakage into the subretinal
space was present on fluorescein angiography (Figure 2B). Optical coherence tomography demonstrated
an area of retinoschisis continuous
with the optic nerve with an associated neurosensory retinal detachment extending through the macula
(Figure 2C and D). The patient has
deferred any surgical intervention.
His intraocular pressure remains well
controlled with timolol maleate in
the right eye.
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A
B
C
0.4
0.8
1.2
1.6
x (mm)
2.0 2.4
2.8
3.2
3.6
4.0
– 0.4 0.0
z (mm)
0.4 0.8
1.2
1.6 0.0
0.4
0.8
1.2
1.6
x (mm)
2.0 2.4
2.8
3.2
3.6
4.0
0.0
0.4
0.4
0.8
0.8
1.2
1.2
1.6
1.6
2.0
2.0
2.4
2.4
2.8
2.8
3.2
3.2
3.6
3.6
4.0
4.0
y (mm)
y (mm)
0.0
0.0
– 0.4
T
TS
NS
N
NI
TI
T
– 0.4
0.0
0.4
0.8
0.4
1.2
0.8
z (mm)
z (mm)
0.0
1.6
0.0
0.4
0.8
1.2
1.6
2.0
2.4
2.8
3.2
3.6
4.0
0
45
90
135
180
225
270
315
360
angle (∗)
x (mm)
Figure 1. Asymmetrical optic nerve cupping. A, Right optic nerve with severe cupping. B, Normal-appearing left optic nerve. C, Studies of the right optic nerve
obtained with the Heidelberg Retina Tomograph (Heidelberg Engineering, Heidelberg, Germany).
Comment. The etiology of the schisis and serous retinal detachment in
this case remains uncertain. The optical coherence tomographic findings demonstrate retinoschisis and
retinal detachment characteristic of
the maculopathy associated with congenital optic pits,3 yet a congenital optic pit could not be identified. The
history of a central scotoma that followed acute rises in intraocular pressure suggests that the increased pressure and optic nerve cupping may
have played a role in the production
of the schisis detachment. We cannot exclude the possibility of a congenital optic pit that was obscured by
the significant cupping of the nerve
head. The patient reportedly had normal fundus examination results in the
past, although photographs are not
available.
Animal studies of Schnabel optic atrophy have demonstrated that
prolonged rises in intraocular pressure may lead to ruptures in the inner limiting membrane and subsequent penetration of vitreous into
(REPRINTED) ARCH OPHTHALMOL / VOL 123, FEB 2005
271
the retrolaminar space.4 In our patient, the sustained rise in intraocular pressure led to severe optic nerve
cupping and may have allowed liquid vitreous to enter the retina via
the nerve fiber layer. This is supported by the direct communication of the schisis cavity with the optic nerve, as shown by optical
coherence tomography, with the
outer layer detachment likely occurring as a secondary event.
We report this case to document the development of macular
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A
B
C
D
Figure 2. A macular schisis detachment of the right eye. A, Fundus photograph of the right eye with fluid extending from the optic disc, a double ring sign
consistent with a retinal detachment and overlying retinoschisis, and deep subretinal yellow precipitates in the macula. B, Fluorescein angiogram demonstrates an
area of hyperfluorescence in the central and inferotemporal margin of the right optic nerve without subretinal leakage. C, Optical coherence tomography of the
right eye with a horizontal scan revealing outer layer retinoschisis connecting to the optic disc. D, A vertical scan through the fovea revealing a neurosensory
retinal detachment with overlying retinoschisis.
schisis and retinal detachment in the
absence of a congenital optic pit.
This case raises the question whether
acute rises in intraocular pressure
from glaucoma can produce structural defects in the optic nerve head
that can lead to a schisis detachment similar to that seen in cases of
congenital optic pits.
David A. Hollander, MD, MBA
Michael E. Barricks, MD
Jacque L. Duncan, MD
Alexander R. Irvine, MD
Financial Disclosure: None.
Correspondence: Alexander R. Irvine, MD, University of California,
San Francisco, Department of Ophthalmology, 10 Koret Way, Suite
K-301, San Francisco, CA 94143
(holland@itsa.ucsf.edu).
1. Lincoff H, Lopez R, Kreissig I, Yannuzzi L, Cox
M, Burton T. Retinoschisis associated with optic nerve pits. Arch Ophthalmol. 1988;106:6167.
2. Spaide RF, Costa DL, Huang SJ. Macular schisis in a patient without an optic disk pit optical
coherence tomographic findings. Retina. 2003;
23:238-240.
3. Rutledge BK, Puliafito CA, Duker JS, Hee MR,
Cox MS. Optical coherence tomography of macular lesions associated with optic nerve head pits.
Ophthalmology. 1996;103:1047-1053.
4. Lampert PW, Vogel MH, Zimmerman LE. Pathology of the optic nerve in experimental acute
glaucoma: electron microscopic studies. Invest
Ophthalmol. 1968;7:199-213.
(REPRINTED) ARCH OPHTHALMOL / VOL 123, FEB 2005
272
Retinal Vascular Occlusion
With Overlying Vitreous
Hemorrhage Masquerading
as a Tumor
Uveal melanoma is the most common primary intraocular malignancy in adults. A collar button–
shaped lesion is most often a
melanoma, particularly when it has
low internal reflectivity and moderate vascularity on ultrasonography. We describe a patient who had
a choroidal mass with these features, which was identifed as a fi-
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